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FACTUAL INFORMATION On final approach to Launceston, maximum nose-up stabiliser trim was insufficient to trim out the nose-heavy force. After landing it was found that 60 golf bags weighing approximately 1,300 kg had not been included on the aircraft load trim sheet. The golf bags belonged to a tour group of 60 people who were to travel some days after this occurrence. They were bulk delivered to the baggage handling area at Melbourne Airport to be forwarded to Launceston on a space available basis to meet a requirement that they be available when the group arrived. The load controller and the baggage loaders were aware that the golf bags were to be moved on a space available basis. The operator's Ramp Manual requires that a load plan must be prepared for each flight. It states that a load plan is an instructional document which specifies where cargo, special load items, livestock, mail, and baggage are to be loaded on an aircraft. The document is produced by the load control section and distributed to members of the loading team so they can perform their duties in the correct loading of the aircraft. It is necessary to follow the load plan to ensure that the load is correctly segregated and all weight and balance requirements are met. When the loading of an aircraft differs from the load plan, the load controller is to be consulted. On this occasion the loading supervisor informed the load controller that the aircraft was full but did not tell him that the 60 golf bags were on board. The load controller was aware that low density cargo was on board. He had not considered it possible to load the golf bags as well and they were not included in the load plan. At the time of the occurrence, the load plan declaration stated: This aircraft has been loaded in accordance with these instructions except for the deviations recorded. The load has been secured in accordance with company regulations. The loading supervisor did not sign the declaration, nor did the load controller seek such certification prior to completing the load and trim sheet. Two load conditions are shown in the following list. The first column is the load displayed on the load plan accepted by the crew. The second column is the estimated load with the extra 60 golf bags. Bay 1 (most fwd) 26 kg 350 kg Bay 2 26 kg 472 kg Bay 3 260 kg 468 kg Bay 4 212 kg 212 kg Bay 5 325 kg 500 kg Bay 6 (most aft) 325 kg 500 kg Bays 1 to 4 are in the forward fuselage and received most of the extra load, thereby adding to the forward centre of gravity. The horizontal stabilizer trim setting listed on the load trim sheet was 1.3 units nose up. The crew did not notice any extra nose-down moment during takeoff. It only became evident during the approach and landing. The investigation team recalculated the trim, taking into account the most probable baggage loading condition. It was concluded that the aircraft was still just within the forward limit of the centre of gravity envelope at takeoff. The required takeoff horizontal stabilizer trim setting would have been 2 units nose up on a 3-unit scale. VH-FKO was the most nose-heavy F28 in this operator's fleet. The load controller stated that to compensate for this he had blanked out the front row of four seats. However, the computer-generated load trim sheet showed that the aircraft was "trimmed by seat row" and, using the code "BLKD 0", showed that no seats were blocked. The requirement for the front row of four seats to remain unoccupied because of balance considerations was not brought to the attention of the cockpit and cabin crews. The aircraft had a fuel load of 4,400 kg in the wing tanks. No fuel was carried in the centre tanks. The centre of gravity moved rearwards with fuel burn. There were 65 passengers including 4 infants who occupied 61 out of 74 seats. The investigation did not determine if passengers were redistributed in the cabin after takeoff, resulting in some or all of the four front seats being occupied. When combined with the nose-down force generated by the weight of the 60 golf bags, any forward movement of passengers would have moved the centre of gravity up to or just outside the forward limit, depending on how many of the front row seats were occupied. The operator uses a system of standard passenger and baggage weights rather than actual weights when compiling a load trim sheet. Accordingly, the actual weights on this flight could not be determined. ANALYSIS Most passenger jet aircraft have a large centre of gravity range and variations from a load plan may be permissible provided the aircraft is loaded within the centre of gravity limits. The F28 aircraft type has only a small tolerance to variations from a load plan which conforms to the manufacturer's specifications. The loading supervisor did not certify that the aircraft had been loaded in accordance with the operator's instructions. Certification is part of the operator's quality assurance safety net. On this occasion the safety net failed. The reason the documentation was not signed could not be clearly established. The operator stated that the reason the loading supervisor did not sign the load plan was an industrial issue rather than a safety issue. The reason maximum nose-up stabiliser trim was insufficient to trim out the nose-heavy force during the approach and landing was not determined. Findings 1. The cargo and baggage were not loaded in accordance with the load plan. 2. The 60 golf bags were not included in the weight and balance calculation on the load trim sheet. 3. Some passengers may not have been seated in accordance with the load plan during the approach and landing. 4. Maximum nose-up stabiliser trim was insufficient to trim out the nose-heavy force during the approach and landing. Significant factors 1. The loading supervisor did not certify for the accuracy of the loading and did not ensure that the load controller was aware of the difference between the load plan and the actual loading. 2. The load controller did not advise the cockpit and cabin crews that the front row of four seats was not to be occupied due to balance considerations. SAFETY ACTION The Bureau of Air Safety Investigation issues safety advisory notice SAN 960031 to the Civil Aviation Safety Authority. The Bureau of Air Safety Investigation informs the Civil Aviation Safety Authority that it is possible, unless adequate notification is given to cockpit and cabin crew, that the movement and reseating of passengers can inadvertently cause an out of balance situation of certain aircraft under certain loading conditions. Furthermore, as a result of this occurrence, the operator advised that it had initiated the following safety actions: 1. Established an aircraft load management group. This group compromises company personnel dedicated to establishing operating procedures to ensure aircraft are loaded in accordance with regulatory and company requirements. The group is also required to conduct audits of all operator ports to ensure all requirements are being met in the field and to develop a training syllabus for all staff involved with the loading of aircraft. 2. Initiated an aircraft load management training course. This course is designed for state managers, operations managers, ramp supervisors, load controllers, senior clerks, senior freight clerks and leading hand loaders. The course syllabus covers all aspects of aircraft loading, weight and balance and the legal requirements of the Civil Aviation Regulations and Civil Aviation Orders. 3. Developed an aircraft abnormal loading alert form to provide staff with a method of reporting any incidents or events which may compromise company procedures or matters of safety with regard to the loading of aircraft. 4. Introduced a requirement for the leading hand who loaded the aircraft, to sign a declaration on the load sheet. The declaration states: "I certify that: - loading staff have been instructed to load this aircraft in accordance with the load plan - all deviations from the load plan have been reported - all ULDS [container] and bulk cargo have been loaded and secured in accordance with company procedures". 5. Appointed a national ramp manager to co-ordinate ramp and loading procedures across the network of ports used by the operator. 6. Introduced a system of examination and certification of the load controllers within handling companies on the international network. A similar scheme is being introduced for the domestic network. 7. Introduced an enhanced computerised weight and balance system. This system provides more automation to the loading process and will be introduced to enhance the documentation for the ramp staff. 8. Provided improved communications between the load controller and leading hand loaders with the introduction of two-way radios at the major stations.
General details
Date: 28 October 1993 Investigation status: Completed 
Time: 18:00 EST Investigation type: Occurrence Investigation 
 Occurrence type:Navigation - Other 
 Occurrence class: Operational 
Release date: 14 May 1996 Occurrence category: Incident 
Report status: Final  
Aircraft details
Aircraft manufacturer: Fokker B.V. 
Aircraft model: F28 MK 4000 
Aircraft registration: VH-FKO 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Melbourne Vic.
Destination:Launceston Tas.
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Last update 24 July 2015